Thrombocytopenia differential diagnosis

Jump to navigation Jump to search

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Sadaf Sharfaei M.D.[2], Farbod Zahedi Tajrishi, M.D. [2]

Overview

Thrombocytopenia has a broad range of potential causes. While a good history and physical examination can be helpful to diagnose some of these causes such as drug-induced thrombocytopenia, they usually don't suffice and further evaluation is often needed. There are also some useful points that may guide the physician to an appropriate diagnosis. For example, asymptomatic, isolated thrombocytopenia most probably suggests ITP, while thrombocytopenia in critically ill, hospitalized patients is usually suggestive of iatrogenic causes (eg. dilution), platelet consumption, bone marrow suppression from infection/sepsis, or even drug-induced thrombocytopenia. One should consider however, that a wide variety of other conditions such as autoimmune disorders, nutrient deficiencies, thrombotic microangiopathies could all as well cause thrombocytopenia.

Thrombocytopenia Differential Diagnosis

Differentiating the diseases that can cause thrombocytopenia:

Category Condition Etiology Mechanism Inherited Acquried Clinical manifestations Para−clinical findings Gold standard Associated findings
Demography History Symptoms Signs
Lab Findings
Fever Rash Bleeding BP Splenomegaly Jaundice Other CBC PBS Bone marrow exam PT PTT UA
Decreased platelet production Platelet destruction in blood Platelet destruction in spleen Plt HB WBC
Hematology Bone marrow disorders Myelodysplastic syndromes[1]
  • Unknown
  • Mutation
+ ± + Elderly Exposure to + Petechiae, purpura, diffuse erythematous rash + Nl + + Nl Nl Nl Bone marrow examination + clinical manifestation
Aplastic anemia[2] + ± ± Biphasic (the young and the elderly) + Nl Nl Bone marrow examination +

laboratory findings

Acute leukemia[3][4] + + ± ± AML in adults
  • Exposure to chemicals
  • Radiation
  • Pre-existent blood disorders
± Petechiae + Nl ±
  • Blast cells
Bone marrow examination
Paroxysmal nocturnal hemoglobinuria (PNH)[5]
  • Mutations
+ + + Any age

(usually younger adults)

Nl ↓/Nl ↓/Nl
  • Hypocellular marrow in certain stages of the disease
Nl Nl Flow cytometry
Condition Etiology Decreased platelet production Platelet destruction in blood Platelet destruction in spleen Inherited Acquried Demography History Fever Rash Bleeding BP Splenomegaly Jaundice Other signs Plt HB WBC PBS Bone marrow exam PT PTT UA Gold standard Associated findings
Thrombotic microangiopathy (TMA) Thrombotic thrombocytopenic purpura (TTP)[6]
  • Deficiency of, or antibodies to, the metalloprotease ADAMTS13  
+ ± + Any age
  • Neurologic manifestations
  • Fatigue due to anemia
+ Petechiae Not common Nl or ↑ + Nl

or ↑

  • Fragmented RBCs
NA Nl Nl Laboratory findings
Hemolytic uremic syndrome (HUS)[7] + ± + Children
  • Exposure to contaminated water or milk
  • Consuming undercooked ground beef
+ Petechiae + Nl

or ↑

  • Fragmented RBCs
NA Nl Nl Laboratory findings
DIC[8][9]
  • Overstimulation of the coagulation system
+ + + Any age + + + + ↓↓ ↑↑ Clinical manifestation + laboratory findings
Nutrient deficiencies Folate, vitamin B12, copper deficiencies[10][11]
  • Decreased platelet production
+ + Any age
  • Malnutrition
  • Alcohol use
Nl Nl Nl Nl Nl Laboratory findings
Condition Etiology Decreased platelet production Platelet destruction in blood Platelet destruction in spleen Inherited Acquried Demography History Fever Rash Bleeding BP Splenomegaly Jaundice Other signs Plt HB WBC PBS Bone marrow exam PT PTT UA Gold standard Associated findings
Congenital platelet disorders[12][13][14] MYH9-related disorders[15] + + Any age, very rare
  • Positive family history
+ Nl Nl
  • Döhle body-like inclusions in peripheral blood neutrophils
NA Nl Nl Nl Genetic study
Bernard-Soulier syndrome[16]
  • Absence of Gp Ib-IX-V  
+ + Children, rare
  • Positive family history
+ Nl Nl Nl Nl Nl Nl Flow cytometry
Gray platelet syndrome[17] + + Rare
  • Positive family history
+

Mucocutaneous

Nl + Nl Nl Nl Nl Nl Genetic study
Wiskott-Aldrich syndrome[18] + + Rare
  • Positive family history
+ Nl Bloody diarrhea Nl Nl Nl Nl Nl Genetic study
Thrombocytopenia with absent radius (TAR) syndrome[19] + + Children
  • Positive family history
+ + Nl Nl Nl or ↑ Nl Nl Nl Evidence of absent radius

+

Laboratory findings

  • Cow's milk allergy
  • Various other anomalies
Fechtner syndrome[20]
  • Mutation of chromosome 22q11-13
+ + Children
  • Positive family history

petechia

+ Mucocutaneous Nl
  • Hearing loss
  • Eye abnormalities
Nl Nl or ↑ NA Nl Nl Clinical manifestation + genetic study
Von Willebrand disease[21]
  • VWF deficiency/dysfunction
+ + Rarely More common with O blood type
  • Positive family history
+ Nl/ ↓ Nl/↓ Nl NA Nl Nl or ↑ Laboratory findings
  • Lifelong bleeding disorder
Category Condition Etiology Decreased platelet production Platelet destruction in blood Platelet destruction in spleen Inherited Acquried Demography History Fever Rash Bleeding BP Splenomegaly Jaundice Other signs Plt HB WBC PBS Bone marrow exam PT PTT UA Gold standard Associated findings
Rheumatologic/autoimmune disorders ITP[22] + + + Any age

petechia

+ Mucocutaneous Nl ↓↓↓ Nl Nl Nl Nl Nl Nl Diagnosis of exclusion
  • Spontaneous remission  
Systemic lupus erythematosus[23] + + Young women, more prevalent in Africans and Asians + Malar rash, generalized maculopapular rash, discoid rash +

Hemoptysis

Nl or ↑ + + Clinical manifestation + serology
Antiphospholipid syndrome[24]
  • Autoantibody-mediated syndrome
+ + + Middle aged women, more in African American and Hispanic population Nl Nl Nl Clinical manifestation + repeated positive tests of aPL
Felty's syndrome[25] + + ± + Rare, young women Nl +
  • Lymphadenopathy
Nl Nl Nl Nl Clinical manifestation
Category Condition Etiology Decreased platelet production Platelet destruction in blood Platelet destruction in spleen Inherited Acquried Demography History Fever Rash Bleeding BP Splenomegaly Jaundice Other signs Plt HB WBC PBS Bone marrow exam PT PTT UA Gold standard Associated findings
Infection-induced Bacterial infections Sepsis[26] + + + Any + ± Nl to ↓ ± ↓/↑ Nl ↑↑ NA +

Depends on the etiology

Clinical manifestation + culture
  • Associated with ↑ mortality
Helicobacter pylori[27]
  • Immune thrombocytopenia
+ + Any Nl Nl Nl NA Nl Nl Nl Clinical manifestation + culture
Tick-borne infection[28]
  • Immune thrombocytopenia
+ + Endemic area like China, Japan, and Korea
  • Being bitten by a tick
+ ± Nl to ↓ ± ± Nl NA Nl Nl PCR
Viral infections HIV[29]
  • Immune thrombocytopenia
+ + + + Any
  • High risk behaviors
  • Close contact
+ ± Nl to ↓ ± ± Isolation of HIV
Other viruses such as rubella, mumps, varicella, parvovirus, hepatitis C, & Epstein-Barr virus[30]
  • Immune thrombocytopenia
+ + Any
  • High risk behaviors
  • Close contact
+ Nl ± ± Nl Nl Clinical manifestation + lab tests
Parasitic infections Malaria[31]
  • Unknown
  • Immune thrombocytopenia
+ + Endemic area
  • Being bitten by a mosquito
+ ± Nl to ↓ ± ± Nl Nl Clinical manifestation + microscopic examination of blood smear
Babesiosis[32]
  • Unknown
  • Immune thrombocytopenia
+ + Rare + ± Nl to ↓ ± ± Nl Nl Clinical manifestation + microscopic examination of blood smear
Category Condition Etiology Decreased platelet production Platelet destruction in blood Platelet destruction in spleen Inherited Acquried Demography History Fever Rash Bleeding BP Splenomegaly Jaundice Other signs Plt HB WBC PBS Bone marrow exam PT PTT UA Gold standard Associated findings
Medication/toxicity Antibiotics/

Antiepileptic[33]

  • Occurrence of drug-dependent, platelet-reactive antibodies
+ + + Any
  • Drug ingestion or injection
Nl ↓↓ Nl NA Nl Nl Nl Clinical manifestation + exclusion of the other causes NA
Heparin-induced thrombocytopenia[34]
  • Anti-heparin/PF4 antibody 
+ + Any
  • Heparin injection
  • Necrotic skin lesions
Nl Nl Nl NA Nl Nl Nl ELISA
Cytotoxic chemotherapy[35] + + Patients with malignancy
  • Drug ingestion or injection
  • Cancer
Nl
  • Megakaryocytic hypoplasia or aplasia
Hematuria Clinical manifestation + exclusion of the other causes
Radiation therapy[36] + + Patients with malignancy + Nl
  • Megakaryocytic hypoplasia or aplasia
Hematuria Clinical manifestation + exclusion of the other causes
GI Chronic liver disease[37] + + Any + + + Nl NA Nl Biopsy
Portal hypertension[38] + + Any + + + Nl NA Nl Clinical manifestation
Category Condition Etiology Decreased platelet production Platelet destruction in blood Platelet destruction in spleen Inherited Acquried Demography History Fever Rash Bleeding BP Splenomegaly Jaundice Other signs Plt HB WBC PBS Bone marrow exam PT PTT UA Gold standard Associated findings
Vascular Giant capillary hemangioma (Kasabach-Merritt syndrome)[39][40] + + Infants Intralesional bleeding Nl Visceral hemangiomas ↓↓ ↓↓ Nl Normocytic normochromic erythrocytes and markedly reduced platelets Normal erythropoiesis, myelopoiesis, and megakaryocytic hyperplasia Hematuria Biopsy
  • Kaposiform hemangioendothelioma
  • Tufted angioma
Cardiopulmonary bypass[41] + + Elderly + Nl or ↑ Nl Normocytic normochromic erythrocytes and markedly reduced platelets NA Hematuria Clinical manifestation
Other Alcohol[42] + + + Any Nl + + Cytopenia, macrocytosis Cytopenia, macrocytosis Nl Clinical manifestation
Post-transfusion purpura[43][44] + + Women + ↓↓↓ Nl Nl NA Nl Nl Nl Positive circulating alloantibody to a common platelet antigen
  • Severe but rare reaction
Gestational thrombocytopenia[45]
  • Might be physiologic adaptation of pregnancy
+ Pregnant women
  • Positive history of mild thrombocytopenia
Nl Nl Nl Nl NA Nl Nl Nl Diagnosis of exclusion
  • Self-limited condition
HELLP syndrome[46][47]
  • Unknown
+ + Pregnant > 25 years + + Nl Schistocytes NA Nl Nl Proteinuria Lab abnormalities
Idiopathic cyclic thrombocytopenia[48] + + + Females with the median age of onset 35 years
  • Misdiagnosed as ITP with uniformly poor responses
Minor mucocutaneous bleeding Nl Nl Nl Reduced platelets and megakaryocytes Megakaryocytic hypoplasia or aplasia Nl Nl Nl Diagnosis of exclusion
Pseudothrombocytopenia[49] + Rare Collected sample in EDTA anticoagulant Nl Nl Nl Low platelet count and platelet clumps Low platelet count and platelet clumps Nl Nl Nl Repeat collecting sample in a heparin tube Nl
Category Condition Etiology Decreased platelet production Platelet destruction in blood Platelet destruction in spleen Inherited Acquried Demography History Fever Rash Bleeding BP Splenomegaly Jaundice Other signs Plt HB WBC PBS Bone marrow exam PT PTT UA Gold standard Associated findings

References

  1. Natelson, Ethan A.; Pyatt, David (2013). "Acquired Myelodysplasia or Myelodysplastic Syndrome: Clearing the Fog". Advances in Hematology. 2013: 1–11. doi:10.1155/2013/309637. ISSN 1687-9104.
  2. Townsley, Danielle M.; Desmond, Ronan; Dunbar, Cynthia E.; Young, Neal S. (2013). "Pathophysiology and management of thrombocytopenia in bone marrow failure: possible clinical applications of TPO receptor agonists in aplastic anemia and myelodysplastic syndromes". International Journal of Hematology. 98 (1): 48–55. doi:10.1007/s12185-013-1352-6. ISSN 0925-5710.
  3. Oshima, Yasuo; Yuji, Koichiro; Tanimoto, Tetsuya; Hinomura, Yasushi; Tojo, Arinobu (2013). "Association between Acute Myelogenous Leukemia and Thrombopoietin Receptor Agonists in Patients with Immune Thrombocytopenia". Internal Medicine. 52 (19): 2193–2201. doi:10.2169/internalmedicine.52.0324. ISSN 0918-2918.
  4. Oshima Y, Yuji K, Tanimoto T, Hinomura Y, Tojo A (2013). "Association between acute myelogenous leukemia and thrombopoietin receptor agonists in patients with immune thrombocytopenia". Intern. Med. 52 (19): 2193–201. PMID 24088751.
  5. Brodsky RA (2014). "Paroxysmal nocturnal hemoglobinuria". Blood. 124 (18): 2804–11. doi:10.1182/blood-2014-02-522128. PMC 4215311. PMID 25237200.
  6. Noris M, Mescia F, Remuzzi G (November 2012). "STEC-HUS, atypical HUS and TTP are all diseases of complement activation". Nat Rev Nephrol. 8 (11): 622–33. doi:10.1038/nrneph.2012.195. PMID 22986360.
  7. Conway EM (October 2015). "HUS and the case for complement". Blood. 126 (18): 2085–90. doi:10.1182/blood-2015-03-569277. PMID 26396094.
  8. Schwameis M, Schörgenhofer C, Assinger A, Steiner MM, Jilma B (April 2015). "VWF excess and ADAMTS13 deficiency: a unifying pathomechanism linking inflammation to thrombosis in DIC, malaria, and TTP". Thromb. Haemost. 113 (4): 708–18. doi:10.1160/TH14-09-0731. PMC 4745134. PMID 25503977.
  9. Kitchens CS (2009). "Thrombocytopenia and thrombosis in disseminated intravascular coagulation (DIC)". Hematology Am Soc Hematol Educ Program: 240–6. doi:10.1182/asheducation-2009.1.240. PMID 20008204.
  10. Clarke, V.; Weston-Smith, S. (2010). "Severe folate-deficiency pancytopenia". Case Reports. 2010 (oct18 2): bcr0320102851–bcr0320102851. doi:10.1136/bcr.03.2010.2851. ISSN 1757-790X.
  11. Blackmer AB, Bailey E (February 2013). "Management of copper deficiency in cholestatic infants: review of the literature and a case series". Nutr Clin Pract. 28 (1): 75–86. doi:10.1177/0884533612461531. PMID 23069991.
  12. Nurden AT, Freson K, Seligsohn U (2012). "Inherited platelet disorders". Haemophilia. 18 Suppl 4: 154–60. doi:10.1111/j.1365-2516.2012.02856.x. PMID 22726100.
  13. Balduini, Carlo L.; Savoia, Anna (2012). "Genetics of familial forms of thrombocytopenia". Human Genetics. 131 (12): 1821–1832. doi:10.1007/s00439-012-1215-x. ISSN 0340-6717.
  14. D'Andrea G, Chetta M, Margaglione M (2009). "Inherited platelet disorders: thrombocytopenias and thrombocytopathies". Blood Transfus. 7 (4): 278–92. doi:10.2450/2009.0078-08. PMC 2782805. PMID 20011639.
  15. Zhang S, Zhou X, Liu S, Bai T, Zhang Y, Wang J, Wang S, Zhang X, Wang B (2014). "MYH9-related disease: description of a large Chinese pedigree and a survey of reported mutations". Acta Haematol. 132 (2): 193–8. doi:10.1159/000356681. PMID 24643058.
  16. Berndt MC, Andrews RK (March 2011). "Bernard-Soulier syndrome". Haematologica. 96 (3): 355–9. doi:10.3324/haematol.2010.039883. PMC 3046265. PMID 21357716.
  17. Michelson AD (January 2013). "Gray platelet syndrome". Blood. 121 (2): 250. PMID 23427340.
  18. Candotti F (January 2018). "Clinical Manifestations and Pathophysiological Mechanisms of the Wiskott-Aldrich Syndrome". J. Clin. Immunol. 38 (1): 13–27. doi:10.1007/s10875-017-0453-z. PMID 29086100.
  19. Al-Qattan MM (November 2016). "The Pathogenesis of Radial Ray Deficiency in Thrombocytopenia-Absent Radius (TAR) Syndrome". J Coll Physicians Surg Pak. 26 (11): 912–916. doi:2476 Check |doi= value (help). PMID 27981927.
  20. Toren A, Amariglio N, Rozenfeld-Granot G, Simon AJ, Brok-Simoni F, Pras E, Rechavi G (December 1999). "Genetic linkage of autosomal-dominant Alport syndrome with leukocyte inclusions and macrothrombocytopenia (Fechtner syndrome) to chromosome 22q11-13". Am. J. Hum. Genet. 65 (6): 1711–7. doi:10.1086/302654. PMC 1288382. PMID 10577925.
  21. Langer F, Obser T, Oyen F, Spath B, Holstein K, Greinacher A, White JG, Budde U, Bokemeyer C, Schneppenheim R (April 2014). "Characterisation of the p.A1461D mutation causing von Willebrand disease type 2B with severe thrombocytopenia, circulating giant platelets, and defective α-granule secretion". Thromb. Haemost. 111 (4): 777–9. doi:10.1160/TH13-06-0462. PMID 24337418.
  22. Zufferey, Anne; Kapur, Rick; Semple, John (2017). "Pathogenesis and Therapeutic Mechanisms in Immune Thrombocytopenia (ITP)". Journal of Clinical Medicine. 6 (2): 16. doi:10.3390/jcm6020016. ISSN 2077-0383.
  23. Abu-Hishmeh M, Sattar A, Zarlasht F, Ramadan M, Abdel-Rahman A, Hinson S, Hwang C (October 2016). "Systemic Lupus Erythematosus Presenting as Refractory Thrombotic Thrombocytopenic Purpura: A Diagnostic and Management Challenge. A Case Report and Concise Review of the Literature". Am J Case Rep. 17: 782–787. PMC 5083062. PMID 27777394.
  24. Artim-Esen, Bahar; Diz-Küçükkaya, Reyhan; İnanç, Murat (2015). "The Significance and Management of Thrombocytopenia in Antiphospholipid Syndrome". Current Rheumatology Reports. 17 (3). doi:10.1007/s11926-014-0494-8. ISSN 1523-3774.
  25. Chavalitdhamrong, Disaya; Molovic-Kokovic, Ana; Iliev, Andrey (2009). "Felty's Syndrome as an initial presentation of Rheumatoid Arthritis: a case report". Cases Journal. 2 (1): 206. doi:10.1186/1757-1626-2-206. ISSN 1757-1626.
  26. Wu, Qin; Ren, Jianan; Wu, Xiuwen; Wang, Gefei; Gu, Guosheng; Liu, Song; Wu, Yin; Hu, Dong; Zhao, Yunzhao; Li, Jieshou (2014). "Recombinant human thrombopoietin improves platelet counts and reduces platelet transfusion possibility among patients with severe sepsis and thrombocytopenia: A prospective study". Journal of Critical Care. 29 (3): 362–366. doi:10.1016/j.jcrc.2013.11.023. ISSN 0883-9441.
  27. Kuwana M (January 2014). "Helicobacter pylori-associated immune thrombocytopenia: clinical features and pathogenic mechanisms". World J. Gastroenterol. 20 (3): 714–23. doi:10.3748/wjg.v20.i3.714. PMC 3921481. PMID 24574745.
  28. Liu Q, He B, Huang SY, Wei F, Zhu XQ (August 2014). "Severe fever with thrombocytopenia syndrome, an emerging tick-borne zoonosis". Lancet Infect Dis. 14 (8): 763–772. doi:10.1016/S1473-3099(14)70718-2. PMID 24837566.
  29. Borges ÁH, Lundgren JD, Mocroft A (July 2015). "Thrombocytopenia and cancer risk during HIV infection". AIDS. 29 (11): 1425–7. doi:10.1097/QAD.0000000000000744. PMID 26098601.
  30. Saeed M, Dabbagh O, Al-Muhaizae M, Dhalaan H, Chedrawi A (November 2014). "Acute disseminated encephalomyelitis and thrombocytopenia following Epstein-Barr virus infection". J Coll Physicians Surg Pak. 24 Suppl 3: S216–8. doi:11.2014/JCPSP.S216S218 Check |doi= value (help). PMID 25518779.
  31. Rodriguez-Morales AJ, Giselle-Badillo A, Manrique-Castaño S, Yepes MC (2014). "Anemia and thrombocytopenia in Plasmodium vivax malaria is not unusual in patients from endemic and non-endemic settings". Travel Med Infect Dis. 12 (5): 549–50. doi:10.1016/j.tmaid.2014.07.006. PMID 25131143.
  32. Nackos E, DeSancho M (March 2014). "Anemia and thrombocytopenia: diagnosis from the blood smear". Blood. 123 (12): 1783. PMID 24783256.
  33. Visentin GP, Liu CY (August 2007). "Drug-induced thrombocytopenia". Hematol. Oncol. Clin. North Am. 21 (4): 685–96, vi. doi:10.1016/j.hoc.2007.06.005. PMC 1993236. PMID 17666285.
  34. Lovecchio, F. (2014). "Heparin-induced thrombocytopenia". Clinical Toxicology. 52 (6): 579–583. doi:10.3109/15563650.2014.917181. ISSN 1556-3650.
  35. Parameswaran, R.; Lunning, M.; Mantha, S.; Devlin, S.; Hamilton, A.; Schwartz, G.; Soff, G. (2014). "Romiplostim for management of chemotherapy-induced thrombocytopenia". Supportive Care in Cancer. 22 (5): 1217–1222. doi:10.1007/s00520-013-2074-2. ISSN 0941-4355.
  36. Bercovitz RS, Josephson CD (2012). "Thrombocytopenia and bleeding in pediatric oncology patients". Hematology Am Soc Hematol Educ Program. 2012: 499–505. doi:10.1182/asheducation-2012.1.499. PMID 23233625.
  37. Loffredo, Lorenzo; Violi, Francesco (2018). "Thrombopoietin receptor agonists and risk of portal vein thrombosis in patients with liver disease and thrombocytopenia: A meta-analysis". Digestive and Liver Disease. doi:10.1016/j.dld.2018.06.005. ISSN 1590-8658.
  38. Jia YP, Lu Q, Gong S, Ma BY, Wen XR, Peng YL, Lin L, Chen HY, Qiu L, Luo Y (September 2007). "Postoperative complications in patients with portal vein thrombosis after liver transplantation: evaluation with Doppler ultrasonography". World J. Gastroenterol. 13 (34): 4636–40. PMC 4611842. PMID 17729421.
  39. Lewis D, Vaidya R. Kasabach Merritt Syndrome. [Updated 2018 Jul 27]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2018 Jan-. Available from: https://www-ncbi-nlm-nih-gov.ezp-prod1.hul.harvard.edu/books/NBK519053/
  40. Vinod, Kolar Vishwanath; Johny, Joseph; Vadivelan, Mehalingam; Hamide, Abdoul (2017). "Kasabach-Merritt Syndrome in an adult". Turkish Journal of Hematology. doi:10.4274/tjh.2017.0429. ISSN 1300-7777.
  41. Ji, Sung-Mi; Kim, Sung-Hoon; Nam, Jae-Sik; Yun, Hye-Joo; Choi, Jeong-Hyun; Lee, Eun-Ho; Choi, In-Cheol (2015). "Predictive value of rotational thromboelastometry during cardiopulmonary bypass for thrombocytopenia and hypofibrinogenemia after weaning of cardiopulmonary bypass". Korean Journal of Anesthesiology. 68 (3): 241. doi:10.4097/kjae.2015.68.3.241. ISSN 2005-6419.
  42. Latvala J, Parkkila S, Niemelä O (April 2004). "Excess alcohol consumption is common in patients with cytopenia: studies in blood and bone marrow cells". Alcohol. Clin. Exp. Res. 28 (4): 619–24. PMID 15100613.
  43. McCrae, Keith R.; Herman, Jay H. (1996). "Posttransfusion purpura: Two unusual cases and a literature review". American Journal of Hematology. 52 (3): 205–211. doi:10.1002/(SICI)1096-8652(199607)52:3<205::AID-AJH13>3.0.CO;2-E. ISSN 0361-8609.
  44. Pavenski, Katerina; Webert, Kathryn E.; Goldman, Mindy (2008). "Consequences of transfusion of platelet antibody: a case report and literature review". Transfusion. 48 (9): 1981–1989. doi:10.1111/j.1537-2995.2008.01796.x. ISSN 0041-1132.
  45. Reese, Jessica A.; Peck, Jennifer D.; Deschamps, David R.; McIntosh, Jennifer J.; Knudtson, Eric J.; Terrell, Deirdra R.; Vesely, Sara K.; George, James N. (2018). "Platelet Counts during Pregnancy". New England Journal of Medicine. 379 (1): 32–43. doi:10.1056/NEJMoa1802897. ISSN 0028-4793.
  46. Barnhart, Lynette (2015). "HELLP Syndrome and the Effects on the Neonate". Neonatal Network. 34 (5): 269–273. doi:10.1891/0730-0832.34.5.269. ISSN 0730-0832.
  47. Haram, Kjell; Svendsen, Einar; Abildgaard, Ulrich (2009). "The HELLP syndrome: Clinical issues and management. A Review". BMC Pregnancy and Childbirth. 9 (1). doi:10.1186/1471-2393-9-8. ISSN 1471-2393.
  48. Go, Ronald S. (2005). "Idiopathic cyclic thrombocytopenia". Blood Reviews. 19 (1): 53–59. doi:10.1016/j.blre.2004.05.001. ISSN 0268-960X.
  49. Tan, Geok Chin; Stalling, Melissa; Dennis, Gretchen; Nunez, Maria; Kahwash, Samir B. (2016). "Pseudothrombocytopenia due to Platelet Clumping: A Case Report and Brief Review of the Literature". Case Reports in Hematology. 2016: 1–4. doi:10.1155/2016/3036476. ISSN 2090-6560.